GW1--05973_Well Construction - GW1_20230912

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.., liVtLL,CONSTRUCTION RECORD
Far/mental 1.12F9NLV:.
This.fano CM be usedi cot stigleor multipTh wells.
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.1.Wilt.CoptOtttoi Infortn#11ott: • ' . .
Ellz3VATER2ONES . - •. - 1 .'
Stefan Smith ROM: TO • bEletttIrtION
Well coottaetor Name 1'7.9 ft; 25 ft / 1 .
3576A
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NC.Wc13 Contractor CcOilication Number :AS..,"OtITERVASINGVeirilitlkiged14-ellsf OR LINER:tiriffilitibkil-',. . •
FROM ' TO .• DIAMETER TTREKNESS ' MATETitAl. •
SAEDACCO . 0 It. 10 . (L' 2 ' 1 ,-1n: SCR-4 0 , PVC
Comp;ulyNome. - • . 1t6INNER:c.ASING.OR',TEBENG3iihiiiial cliktl.-1oil&-.,..
• ' -FROM TO . , D[AMETER THICKNESS MATERIAL
2..Welltonitruetinti PSI.tilt-i: 2023-20-05-MW-5-RWO •ft, .ft,
Lin;an Gni/1,7647rpeipift,trix-Cpunty.Stom,Yurfenree,14041,cir-P . ,
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3.101c111.ite itheel:well us'p ". • ?,17:-SCREEN. . • . .. .
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• Water Supply Well:• • , " FROM. TO ',at-A.14E1m SLOT SIZE 'MI(R NESS 1 MAI-MIA r,
igrionliural
10 • 01:- 25 It. 2 i!!1, , • .010 9cii7 4 0 PVC. .
Elt . OhltinicipaPPuldic
in,'
. . EiGetithermal(Heating/tooling Stimly) EIResidential•Water ft.•SupPlY(single) - ft' .. •
`-YIlliGROUT",....„... • '' '-,. ,:....-c.,-t-r" , - " '
DindustrialiCommercial • Cllicsidential WateCSupp1S-(sicueu--)
rnosi— EN-11,-LiCE.- --T-METVI"'OD-aAIID-ON-,.T
0 ktipation . ' , - - - . - . 0 -.ft... -6 ft, Portland Pour . . -. , •
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NutiWafFSH pp ly NVell: . .. .
ft. ft.
55Monitoriog . . . .•PRecoNmy • _
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Injection Went • • • . ft,- . IL
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El Aquifer celiairgi . ilGioilMlwalcr Reincdiation ,!tst•.:!SA:NINGelp,VIELPPACEtiCintillizahle --' --.
• ,. . _. .. -,- . - . - - FROM ,.TO- i :11ATErittAt. • •RSIPLACEitincr muntou
1:14ktinikr:§(cirag0 ant!lIccoitq 12SHillifty itiiiiliS.:., 8 -ft,: '25 ft. 'Sand(' 2
. LIAttillecTTCST - OSIOttristatce Pr.Aitiage . . .
. . .•ft.. . • 1t.. .
- . Orgxperinicutil Teehootog OStraSideocc,eointo I. •. ';4•20,'ORILLING,LOGIaltaeli-idditiariiil glee&it ite6i4irvl' • .
Ecrad*nisti Clused Loop) DTracer .FROM-' TO " : USSCREPTION(*Aar.liardku.miltnitt4 ow.ems ssre.atm
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OGeotheimal fileatingtooling Retum) 1:30ther.tetplain untier.#21-Itemosks) ° .ft. 12 h., ' Clayey silt •. .
• . 12 ft: 25 fL Silt ' . F •
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. 4..Dato•Well(i)Completed; 8 7 7-2 Won uud441-1R • I. 1 rErviVED
'ft. ft. - ‘ k.,••I..... .
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54,Well Lecattinit .ft.- ft, 1
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Jimmy's Daytona SEP 1 2 2023..rt. it
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FacilityMwnerNante . Facility lti#.(Itappjkilble) ft, .
inforingizn Prtn-ut40,3 ,,-•
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2001 W. Vandalia Rd., Greensboro; NC, 27407 . - ' . ft. ft,• . 17/1CiL'XI
• Pkvii.did;,iiklicss citY-i614 ii13' "qt.;11/151ARICS •
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Guilford • - 7.852175495 - -Two foot bentonite seal from 6-8' .
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Conuty . parcel hlatiticalion No.(Pla.1 .
li-initiitle.aiiillingiintle in de-greeskiitiutes/secinds pi!'dositital-dtgries:• 22,ecitimmti,,,. 1, • •
(it t;ell trotd,*tie latflott it.ifilekst)
36.020582 N 79.839812 w - _,,..- . 'fl • 8/10/2023
Signu el*Ce,fied Welt Contra:my', . Date
6.Is(nee)the:well4): X1Pernianettt or QTenttiorory . .• l• '• . . •
ity signing,'kir„kink.'Iremby ereEy 4c2i Ihz:wets)P.=(Xi-re,)tkft#DiFled ilr:diyonlazkV
with/54 JVCA,C 02C.91(k)or ISA WC4002C,O2(10 WdJ Conituverion Standards and Mar o
7.Is this a reintir tit att eilititag well:• f:IY or EN° 4.-4,0:-.7.0/611 ief Orr:ms Nen provided rearm‘tvil ris?ier,
If tin;s:Is17 NikTik.11.11 twit hoc10.1 Veil 4%111.511104,141•tithrtnalielt arid Liyioln rhe iunure of:the
riot&ruder nrrernarks scrtian ai-im Ag back of titLykrou.. • . ' 23:Site diagram or.additinual wen.details:
You.may use the back of this pdgi to providt'additional well Site details or tielL
8.Nuutberof Welts eonstructed: 1 • •coast:meth:It details. You inns 1114 attack additional Oakes if titscesSaty..
For ntaltiple ktietihNI all.'OM-Miter supply wells ONLY Atli the.sanag construdion,you coo
rLufrnIlt 0.! fOrrn. - SUBMITTAL INSTUCTIONS i', •
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0.7atai Wen depth below land stirfocei . 25 - - - - . (fit.) .244 For ALL SWIIE: Sahntit IhtS knit uithiti 30 days of cOmptetiOtiof well
For nyultiplcii:ellslistall depth's ird(4.11rent femunp2110'Und.„?@ MO constmetioni to.Ike to/towing: • •
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10.Static water love/below lops of II&S.IIK: 17,9 (ilt,)• .Diii.5imi of.Wuter ResoureeS,'Information Pessing unit, . .
//wok(triag Isiinire eau*,iue"+" • /617 Mail.Serciee.Center,Raleigh,NC-27099-I8 t7•
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11.Borehole diameter;8;25" . .1.in.) 24b.For Irtieetion Weill ONLY:. In addition to sending the ferny to the address-in
24kabeiie,also submit a-.eopy of tins faun within-39 daYs of completion of well
12.-Well consttvellint method:B8A constniellou tots following• i
(i.e.sager,iotaty;cable.-direct push.etc...} - . I . .
DivIsiott Of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . -1636 Mail Seri:ice Ceitter,Raleigh,NC 27699-1636
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' 24e.For Water Sunnite&hajettion.Wells:.
f3,04 741Fld(Out) Method of tat;
Also submit'one bany of this.:kith Within 39.daysolcOnipletion.of
well construction•to the county health department.of the coinny whom
13h.Disinfection typi..: Amounh.
• constwctcd. ' ,Faun GW,1 Nash Catalina Dcpanmentof Eskiromtritt and Natural Resources,DtViii0114 Wafer Rerrourtm Revised 44=1013 -
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